New Zealand patients have a higher melanoma burden in sentinel nodes and completion lymphadenectomy than patients in MSLT-II.

New Zealand has the highest rate of melanoma-related mortality in the world. Access to immunotherapy and radiology is limited and surgical treatment of regional disease remains important. A recent pilot study of a single health district observed a higher nodal melanoma burden than was reported in the second Multicentre Selective Lymphadenectomy Trial (MSLT-II). In this study, a series of regional censuses were undertaken covering the 10 years immediately prior to the publication of MSLT-II. The study population was seven District Health Boards covering 62.2% of the population of New Zealand across a 10-year period preceding MSLT-II. The primary outcomes measured were the size of sentinel lymph node metastases and non-sentinel node (NSN) positivity on completion lymph node dissection (CLND) for patients with a positive sentinel lymph node biopsy (SLNB). In the 2323 SLNB identified, the mean sentinel lymph node metastatic deposit size was larger compared to MSLT-II (2.55 vs. 1.07/1.11 mm). A greater proportion of New Zealand patients (44.2%) had metastatic deposits larger than 1 mm compared to MSLT-II (33.2/34.5%) and the rate of non-sentinel node involvement on CLND was also higher (22.2% vs. 11.5%). These findings indicate that New Zealand is a high-risk population for nodal melanoma metastases. Due to these differences, the conclusions of MSLT-II may not be able to be applied to melanoma patients in the 7 regions studied in New Zealand.

Melanoma sentinel lymph node biopsy and completion lymph node dissection: A regional hospital experience.

Completion lymph node dissection (CLND) following positive sentinel lymph node biopsy (SLNB) for cutaneous melanoma is a topic of controversy. The second Multicenter Selective Lymphadenectomy Trial (MSLT-II) suggested no survival benefit with CLND over observation amongst patients with a positive SLNB. The findings of the MSLT-II may have limited applicability to our high-risk population where nodal ultrasound and non-surgical melanoma treatment is rationed. In this regional, retrospective study, we reviewed primary melanoma, SLNB and CLND histopathological reports in the Bay of Plenty District Health Board (BOPDHB) across a 10-year period. The primary outcomes measured were size of sentinel lymph node metastases and non-sentinel node (NSN) positivity on CLND for patients with a positive SLNB. In the 157 SLNB identified, the mean sentinel lymph node metastatic deposit size was larger in BOPDHB compared with MSLT-II (3.53 vs 1.07/1.11mm). A greater proportion of BOPDHB patients (54.8%) had metastatic deposits larger than 1mm compared with MSLT-II (33.2/34.5%) and the rate of NSN involvement on CLND was also higher (23.8% vs 11.5%). These findings indicate that the BOPDHB is a high-risk population for nodal melanoma metastases. Forgoing CLND in the context of a positive SLNB may place these patients at risk.

SEROPREVALENCE OF TOXOPLASMA GONDII IN MARKET HOGS COLLECTED FROM U.S. SLAUGHTERHOUSES.

Foodborne pathogens continue to pose a public health risk and can cause serious illness and outbreaks of disease in consumers. The consumption of raw or undercooked infected meat, such as pork containing infectious stages of Toxoplasma gondii, may be a major route of transmission to humans. Given the occasional presence of T. gondii in pork meat and the frequent use of pork for products not intended to be cooked, such as dry-cured ham, a potential risk exists for T. gondii transmission to consumers of these products. The purpose of this study was to determine the seroprevalence of T. gondii in U.S. market hogs and sows at slaughter. A total of 20,209 sera samples collected from 22 U.S. slaughterhouses, including 15 of the top 25 largest slaughter plants in the United States, were tested for T. gondii antibodies using a commercial ELISA assay. Seroprevalence in this study was 0.74%, with a herd prevalence of 10.86%. We compared seroprevalence of T. gondii in market hogs vs. sows from a separate but geographically similar set of slaughterhouse locations, with serum samples screened using the T. gondii modified agglutination test. This set of market hogs demonstrated 0% seroprevalence for T. gondii, while sows from geographically similar but separate slaughter facilities demonstrated a seroprevalence of 1.03%. Overall, both analyses show low seroprevalence of T. gondii in U.S market hogs and sows, respectively, and a marked drop in prevalence in market hogs and sows compared to previous studies.

Skin shop: long-term management and follow-up of narrowly and incompletely excised non-melanomatous skin cancer.

BACKGROUND: 'Skin Shop' is a model of care at a high-volume tertiary centre that describes a registrar-lead skin cancer service under consultant supervision. Ninety-two percent of lesions are completely excised, 4.2% are narrowly excised and 3.2% are incompletely excised. Current international guidelines suggest re-excision of incompletely excised non-melanomatous skin cancer (NMSC); however, there is a lack of robust evidence to suggest how these lesions should be optimally managed. We describe how narrow and incompletely excised NMSC are managed in the 'Skin Shop' and present rates of recurrence. METHODS: Retrospective analysis of all lesions excised between December 2014 and June 2019. Lesion type, histological margin, presence of high-risk features, management, presence of residual tumour in re-excision and follow-up duration were recorded. Rates of clinical recurrence were documented. RESULTS: From 5821 lesions excised, a total of 394 NMSC (245 basal cell carcinoma (BCC), 128 squamous cell carcinoma (SCC) and 21 Basosquamous cell carcinoma) were narrowly or incompletely excised. A total of 135 (34.3%) lesions were observed in clinic for recurrence, 133 (33.8%) lesions underwent re-excision, 81 (20.6%) lesions underwent GP surveillance and 14 (3.6%) lesions received radiotherapy. Mean specialist clinic follow-up was 12.4 months. Fourteen lesions recurred (3.5%, 10 BCC, 3 SCC, 1 basosquamous) of which 12 underwent re-excision. The risk of recurrence for narrow and incompletely excised BCC was 2.9% and 10%, respectively. The corresponding rates for SCC were 2.2% and 3.3%, respectively. CONCLUSION: Skin Shop is an effective model with low rates of narrow and incompletely excised NMSC. Risk of recurrence of these lesions is low with our current practice.

Culturing Rat Sympathetic Neurons from Embryonic Superior Cervical Ganglia for Morphological and Proteomic Analysis.

Sympathetic neurons from the embryonic rat superior cervical ganglia (SCG) have been used as an in vitro model system for peripheral neurons to study axonal growth, axonal trafficking, synaptogenesis, dendritic growth, dendritic plasticity and nerve-target interactions in co-culture systems. This protocol describes the isolation and dissociation of neurons from the superior cervical ganglia of E21 rat embryos, followed by the preparation and maintenance of pure neuronal cultures in serum-free medium. Since neurons do not adhere to uncoated plastic, neurons will be cultured on either 12 mm glass coverslips or 6-well plates coated with poly-D-lysine. Following treatment with an antimitotic agent (Ara-C, cytosine ß-D-arabinofuranoside), this protocol generates healthy neuronal cultures with less than 5% non-neuronal cells, which can be maintained for over a month in vitro. Although embryonic rat SCG neurons are multipolar with 5-8 dendrites in vivo; under serum-free conditions, these neurons extend only a single axon in culture and continue to be unipolar for the duration of the culture. However, these neurons can be induced to extend dendrites in the presence of basement membrane extract, bone morphogenetic proteins (BMPs), or 10% fetal calf serum. These homogenous neuronal cultures can be used for immunocytochemical staining and for biochemical studies. This paper also describes optimized protocol for immunocytochemical staining for microtubule associated protein-2 (MAP-2) in these neurons and for the preparation of neuronal extracts for mass spectrometry.

A Modification of the Webster-Bernard Lip Reconstruction.

We report a modification of the Bernard-Webster lip reconstruction technique which uses the Burrows triangles as V-Y advancement flaps rather than excising them. A 44-year-old white, nonsmoking man presented with a 2-cm cutaneous squamous cell carcinoma of the right lower lip. Oncological resection required excision of 40% of the lower lip to the modiolus. A modified Bernard-Webster flap was used to reconstruct the full length of the lip with minimal donor morbidity.

Low prevalence of viable Toxoplasma gondii in fresh, unfrozen American pasture-raised pork and lamb from retail meat stores in the United States.

In a national survey of fresh, unfrozen, American pasture-raised lamb and pork, the prevalence of viable Toxoplasma gondii was determined in 1500 samples selected by random multistage sampling (750 pork, 750 lamb) obtained from 250 retail meat stores from 10 major geographic areas in the USA. Each sample consisted of a minimum of 500g of meat purchased from the retail meat case. To detect viable T. gondii, 50g meat samples of each of 1500 samples were bioassayed in mice. Viable T. gondii was isolated from 2 of 750 lamb samples (unweighted: 0.19%, 0.00-0.46%; weighted: 0.04%, 0.00-0.11%) and 1 of 750 pork samples (unweighted: 0.12%, 0.00-0.37%; weighted: 0.18%, 0.00-0.53%) samples. Overall, the prevalence of viable T. gondii in these retail meats was very low. Nevertheless, consumers, especially pregnant women, should be aware that they can acquire T. gondii infection from ingestion of undercooked meat. Cooking meat to an internal temperature of 66°C kills T. gondii.

Cutaneous melanoma: an audit of management timeliness against New Zealand guidelines.

AIM: The New Zealand Ministry of Health's "Faster Cancer Treatment" programme aims for timely care for patients with cancer, including melanoma. Melanoma care guidelines detail investigation and treatment timeliness standards. This audit assesses compliance with these. METHOD: Patients admitted to Waikato Hospital for melanoma surgery during the year ending February 2016 were retrospectively identified. Time intervals between care events were calculated. Demographic, lesion, surgical and histopathological characteristics were analysed. RESULTS: For patients referred with skin lesions suspicious for melanoma, referral to first treatment (Standard 2.1), referral to diagnostic skin biopsy (Standards 2.2, 2.3), biopsy histology report to first treatment (Standard 2.4), referral to first treatment (Standards 2.2, 2.3, 2.4, 4.4) and biopsy to first treatment (Standards 2.4, 4.4) compliance was 0%, 17.6%, 21.7%, 9.3% and 21.7%, respectively. For patients referred with biopsy-confirmed melanomas, referral to first treatment (Standards 2.2, 2.4) and skin biopsy to first treatment (Standards 2.2, 2.4, 4.4) compliance was 42.2% and 42.9%, respectively. CONCLUSIONS: Compliance was low. Attention to logistical constraints in the department reviewed may improve this. Recommendation inconsistencies within and between suspicious-lesion and confirmed-diagnosis referral pathways suggest the investigation and treatment events selected and intervals mandated by the guidelines may usefully be reconsidered.

New Zealand plastic surgeons' life-time contribution to peer-reviewed literature.

AIM: The New Zealand Medical Association commits the New Zealand doctor to evidence-based medicine, scholarship, teaching, collaboration and communication. To assess this commitment, one measure, contribution to the peer-reviewed literature, was examined for one group of New Zealand doctors: plastic surgeons. METHOD: Plastic surgeons with a current practising certificate were identified on the New Zealand medical register (April 2016). Scopus database was searched for publications by each. RESULTS: Sixty-five surgeons authored 541 unique items in 134 journals, generating 8,047 citations. Between medical graduation and specialty qualification, a mean 1.8 items were published per practitioner (range 0-11). Twenty-three practitioners (35.4%) did not publish during this time. Between specialty qualification and the end of 2015, mean number of items published per surgeon was 7.3 (range 0-97). Thirteen (20.0%) surgeons had not published since specialist qualification. The general trend was for surgeons to become less productive with increasing time in practice. Mean surgeon h-index was 4.4 (range 0-26). Four surgeons (6.2%) had not published at any time. CONCLUSION: As a group, but with exceptions and less so in later practice, New Zealand plastic surgeons would seem to demonstrate commitment to evidence-based medicine, scholarship, teaching, collaboration and communication expected of a New Zealand doctor, as evidenced by peer-review publication.

Flow-through flap for salvage of fibula osseocutaneous vascular variations: a surgical approach and proposed modification of its classification.

The osseocutaneous fibula free flap is commonly used in mandibular reconstruction. Clinically important anatomic variants of the donor vessels have been reported. The authors describe a rare variant encountered while raising an osseocutaneous fibula flap. The fibula was supplied by the peroneal vessels and the overlying skin paddle was supplied by musculocutaneous perforators arising from the posterior tibial vessels. By raising 2 separate free flaps and configuring them in microvascular series with the fibula acting as a flow-through flap, the reconstruction was successful. Although the anatomic variant has been described, the authors' approach to it has not. The benefits of this method over other options include preservation of a skin paddle for monitoring and watertight oral closure and a long pedicle to the skin paddle permitting a wide arc of movement. The authors suggest a modification to the existing classification of perforators to the lateral leg skin to guide intraoperative decision making.

Modified total thigh musculocutaneous flap: 'operation of last resort' for massive pressure ulcers.

Massive bilateral pressure ulcers of dependent areas may complicate spinal cord injuries. These may be life threatening to patients and challenging for reconstructive surgeons. In massive recurrent ulcers, local tissue is either inadequate or previously exhausted. The total thigh musculocutaneous flap is an operation of last resort; we present a new variation of this procedure and a case of life threatening pressure ulcers with underlying osteomyelitis. A paraplegic patient had recurrent, extensive, bilateral pressure areas with some preserved tissue bridges. The nature of the pressure areas and lack of local options in this patient required modification of previously described total thigh flaps. An extended total thigh flap was partially de-epithelialised to fill the extensive sacral defect and a tunnelled extension was fashioned to cover the contralateral trochanteric defect. The timing of surgery was determined by balancing pre-operative nutritional optimisation against life-threatening drug resistance of infective organisms. The total thigh flap can close massive bilateral pressure ulcers. Modifications are presented which preserve viable local tissue and demonstrate the versatility of this technique. It remains a 'last-resort' salvage procedure.

The future of the New Zealand plastic surgery workforce.

AIMS: The New Zealand (NZ) plastic and reconstructive surgery (PRS) workforce provides reconstructive plastic surgery (RPS) public services from six centres. There has been little analysis on whether the workforce is adequate to meet the needs of the NZ population currently or in the future. This study analysed the current workforce, its distribution and future requirements. METHODS: PRS manpower data, workforce activities, population statistics, and population modelling were analysed to determine current needs and predict future needs for the PRS workforce. The NZ PRS workforce is compared with international benchmarks. Regional variation of the workforce was analysed with respect to the population's access to PRS services. Future supply of specialist plastic surgeons is analysed. RESULTS: NZ has a lower number of plastic surgeons per capita than comparable countries. The current NZ PRS workforce is mal-distributed. Areas of current and emerging future need are identified. CONCLUSIONS: The current workforce mal-distribution will worsen with future population growth and distribution. Up to 60% of the NZ population will be at risk of inadequate access to PRS services by 2027. Development of PRS services must be coordinated to ensure that equitable and sustainable services are available throughout NZ. Strategies for ensuring satisfactory future workforce are discussed.

Appropriate working hours for surgical training according to Australasian trainees.

BACKGROUND: The demands of surgical training, learning and service delivery compete with the need to minimize fatigue and maintain an acceptable lifestyle. The optimal balance of working hours is uncertain. This study aimed to define the appropriate hours to meet these requirements according to trainees. METHODS: All Australian and New Zealand surgical trainees were surveyed. Roster structures, weekly working hours and weekly 'sleep loss hours' (<8 per night) because of 24-h calls were defined. These work practices were then correlated with sufficiency of training time, time for study, fatigue and its impacts, and work-life balance preferences. Multivariate and univariate analyses were performed. RESULTS: The response rate was 55.3% with responders representative of the total trainee body. Trainees who worked median 60 h/week (interquartile range: 55-65) considered their work hours to be appropriate for 'technical' and 'non-technical' training needs compared with 55 h/week (interquartile range: 50-60) regarded as appropriate for study/research needs. Working ≥65 h/week, or accruing ≥5.5 weekly 'sleep loss hours', was associated with increased fatigue, reduced ability to study, more frequent dozing while driving and impaired concentration at work. Trainees who considered they had an appropriate work-life balance worked median 55 h/week. CONCLUSIONS: Approximately, 60 h/week proved an appropriate balance of working hours for surgical training, although study and lifestyle demands are better met at around 55 h/week. Sleep loss is an important determinant of fatigue and its impacts, and work hours should not be considered in isolation.

Society's expectation of the role of the doctor in New Zealand: results of a national survey.

AIMS: To describe the perceptions of the New Zealand public as to the role of the doctor in 2010. METHODS: Telephone survey of 502 individuals throughout New Zealand during May 2010. The questions were based on a United Kingdom survey with added questions in respect of culture, equity and resource allocation. The data were weighted by gender and age according to the 2006 population census. RESULTS: Most respondents (82%) wanted to see a doctor first if they had a new concern about their health; 7% a nurse and 5% a pharmacist. Most respondents agreed (88%) that when visiting a doctor, getting an accurate diagnosis was their top priority. In respect of a doctor's personal qualities, integrity was expected (94%), as was compassion (89%). Most respondents (78%) agreed that they expected a doctor to be the leader of the healthcare team. Most agreed (70%) that there is limited money available and doctors must consider how best to use it for all patients and that doctors (82%) need to be involved in decisions about health spending. CONCLUSION: This comprehensive New Zealand survey provides important information about public perceptions of the role of the doctor and is a basis for workforce planning and future comparisons.

Comparison of central venous pressure and venous oxygen saturation from venous catheters placed in the superior vena cava or via a femoral vein: the numbers are not interchangeable.

OBJECTIVE: To compare venous pressure and haemoglobin oxygen saturation measured from a catheter in the superior vena cava (SVC) with a catheter inserted via the femoral vein, and to assess the agreement of these measurements. To assess the effect of intra-abdominal pressure and intrathoracic pressures on these measurements. DESIGN, SETTING AND PARTICIPANTS: Prospective study of patients in an adult intensive care unit, Alfred Hospital, Melbourne, Australia. MAIN OUTCOME MEASURES: Central venous pressure (CVP), femoral venous pressure (FVP), venous haemoglobin oxygen saturation in the SVC (SO2C) and via the femoral vein (SO2F), agreement between these measures using the Bland-Altman method, and the effect of intra-abdominal pressure and intrathoracic pressure. RESULTS: 43 patients were included; the mean bias for FVP -CVP was 1.05 mmHg (95% CI, 0.30-1.79 mmHg), with limits of agreement of -3.79 to 5.89 mmHg (95% CI, -5.08 to 7.18 mmHg). The bias for SO2F -SO2C was -3.21 (95% CI, -6.33 to -0.10), with limits of agreement of -22.43 to 16.01 (95% CI, -27.81 to 21.39). Intra-abdominal pressure had a significant (P < 0.01) effect on both the FVP and on the difference (FVP -CVP). CONCLUSIONS: This study demonstrates poor agreement between CVP and FVP and between SO2C and SO2F and that the measurements taken from these two sites are not interchangeable clinically.